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HIV & AIDS in USA

There are currently around 1.1 million people living with
HIV in the United States of America (USA), with 16 percent unaware of their infection.
12 Since the beginning of the
HIV and
AIDS epidemic, 600,000 people have died of AIDS-related illnesses in the United States of America.
3

Although the USA may be the greatest national funder of the
global HIV epidemic (largely through the President's Emergency Plan For AIDS Relief, or
PEPFAR), it is still facing a major ongoing HIV epidemic itself, with around 50,000 new infections per year.
Stigma and discrimination continue to hamper people's access to
HIV prevention,
testing and
treatment services, fuelling the cycle of new infections.

The USA lacked a comprehensive plan on HIV until 2010 when President Obama created a National HIV/AIDS Strategy. It is structured around three core aims: reducing new HIV infections, increasing access to care and improving health outcomes for people living with HIV, and reducing HIV-related disparities and health inequities.
4

A 2010 study found that wealth also determines vulnerability; HIV prevalence was four times higher among heterosexual people in poor urban neighbourhoods than the national average.
5 Within these high-poverty areas HIV prevalence didn't change depending on race or ethnicity. Rather, higher HIV risk was attributed to high HIV prevalence, limited access to health care and other basic services, and high rates of
substance abuse and
incarceration.
6

It is not solely individual behaviour, but also a person's sexual network which determines an individual's HIV risk in the USA. For example,
African American males are much more likely to be infected because of the high HIV prevalence in this community and a tendency to choose racially similar partners.

The table below compares the percentage of new HIV diagnoses among various ethnic groups to the percentage of the population that each ethnic group represents. There were 42,181 new infections in 2011.
7

A Kaiser Family Foundation survey reported the concern about HIV among the African American community. 40 percent of this community reported feeling 'very concerned' about being infected with HIV, compared to 11 percent among the white community. This figure jumps up to 50 percent among
young African Americans - those under 30 years of age. White people are less than half as likely to know a friend or family member
living with HIV, or who has died of an AIDS-related illness.
11

Hispanics/Latinos

Hispanics/Latinos accounted for 22 percent of new HIV infections in 2011.
12

This is relatively proportionate to their share of 17 percent of the USA population, but they are still more than 3 times as likely to be infected with HIV than whites.
1314

It is estimated that 1 in every 36 Hispanic/Latino men will be diagnosed with HIV in their lifetime compared to 1 in 106 Hispanic/Latino women.
15 Of all male diagnoses in 2011, 79 percent were transmitted via
sex between men, 11 percent via unprotected heterosexual sex, and 8 percent via
injecting drug use. Among females, 86 percent of HIV infections were the result of unprotected heterosexual sex, and 14 percent injecting drug use.
16

Language barriers, cultural factors, and migration patterns have been identified as barriers to HIV prevention and treatment within the Hispanic/Latino community.
17

Men who have sex with men

MSM are the group most affected by HIV in the USA. The concentrated epidemic among MSM increases the likelihood of HIV exposure for all MSM in the country, partially accounting for the high rate of transmission. Alongside this, only 66 percent of MSM
living with HIV in 2011 were aware of their infection. This left 34 percent of MSM remaining unaware of their risk of transmission to others, or that their own health was deteriorating.
19

The availability of
antiretroviral treatment may also have lessened the fear surrounding HIV, leading to complacency about using
condoms.
21 This complacency is evident in Washington D.C, where a study revealed 40 percent of MSM had not used a condom with their last sexual partner. The study also found that, contrary to popular belief, men older than 30 had more sexual partners and were less likely to use condoms or get tested than their younger counterparts.
22

People who inject drugs

Among those living with HIV in the USA, around 16 percent are people who inject drugs (PWID). The majority of PWID who are living with HIV are
African Americans, both for males and females.

Throughout the epidemic, prevention efforts among PWID have been controversial. At the start of the HIV epidemic,
needle exchange services – where users exchange their used needles for new clean ones – were not permitted any federal funding, even though in some areas of the USA these programmes have proved to be successful in reducing the rate of HIV transmission.
2425 The ban on federal funding for needle exchanges was lifted in 2009. However, in a controversial move Congress failed to allocate funding for needle exchanges for the 2012 fiscal year.
26

Young people

Young people aged 13-24 accounted for 21 percent of new HIV infections in 2011.
27

This is despite only making up 17 percent of the USA population. Infections among young people follow the same trends as other
vulnerable groups. Of all infections among young people in 2010:

The number of AIDS diagnoses among young people has increased by 29 percent since 2008.
30 A sense of complacency, or an attitude of 'it doesn't affect me' has prevented young people from
testing for HIV and subsequently accessing antiretroviral treatment (ART) to prevent the onset of
AIDS.

Geographical variations

Geographical differences in HIV and AIDS prevalence are due to concentrations of
key populations that are typically at risk of HIV infection in certain areas, and variations in healthcare between different states.

Key populations

The epidemic was once concentrated mainly in the
gay populations on the East and West coasts. However, in recent years HIV has also become increasingly prevalent within the
African American and Latino communities in many Southern states as well as certain urban areas in the Northeast and West.

The South continues to represent a majority of all HIV and AIDS relation diagnoses, with the Northeast very close behind. However, both areas have seen improvements, or at least stability, in their diagnoses between 2008-2011. This represents the success of targeted HIV prevention, testing and treatment services in specific areas. Despite this, the rates (per 100,000 population) of new HIV diagnoses in the South are still more than double that in the Midwest (20.9 v 9.3 respectively).
31

Healthcare variations

It has become increasingly clear that the quality of
HIV prevention and
treatment services an individual receives is influenced as much by where they live, as by their socio-economic group.

In 2010, a report criticised the response to the HIV epidemic in the 17 states in "the South", where the risk of HIV transmission and mortality is highest.
32 Factors which contribute towards this include: poverty, poor access to healthcare relative to the rest of the country, a focus on
abstinence based sex education, and laws that criminalise HIV transmission and restrict
harm reduction programmes for PWID.
33

A study examining data from across the country also found that, for socioeconomic reasons, non-white men and particularly non-white women residing in the South experience the worst clinical outcomes after being diagnosed with HIV.
34 AIDS-related mortality rates vary geographically, far more than within other highly developed countries where national health insurance programmes or health policies are geographically uniform.
35

HIV and AIDS prevention in the United States of America

National prevention strategy

One of the three components of the USA's National HIV/AIDS Strategy is the reduction of new HIV infections. The Strategy recommends that
HIV prevention efforts are intensified in the communities where HIV is the most heavily concentrated, and that care should not endorse one prevention method, such as
condom use,
education or
testing, over another. Instead, it insists that ‘overlapping,
combination’ prevention approaches that have been proven to work and are cost-efficient be used to target high-risk populations including MSM, African Americans, Latino Americans and PWID.
36

Treatment as prevention

Taking
antiretroviral treatment significantly lowers the risk of HIV transmission to others - this is known as
treatment as prevention (TasP). Attention has been placed upon people living with HIV, stating that "prevention for people who are HIV-positive is critical to reducing new HIV infections".
37

Continuing the TasP theme, the USA announced in July 2012 that an antiretroviral drug for use as a
pre-exposure prophylaxis had been approved, for HIV-negative persons to take treatment as a form of HIV prevention. The drug with the brand name ‘Truvada’ can now be prescribed for high-risk groups, such as the partners of HIV-positive people and
men who have sex with men.
38

Targeted prevention

American health authorities are placing increased emphasis on the role that 'social determinants of health' such as a person's age, class, race, living environment and poor access to healthcare have on their risk of becoming infected with HIV.
39 For example, there is an increasing number of new HIV infections among people over 50 years old, and some communities have started to provide HIV education for the
ageing generation.
4041 Targeting HIV prevention initiatives at people of high-risk populations has been shown to be effective globally.

Prevention campaigns

The Centers for Disease Control and Prevention (CDC) run multiple campaigns that aim to take the taboo out of HIV. Specifically, their 5-year 'Act Against AIDS' campaign has many strands that target different population groups, for example:

'Let's Stop HIV Together' - launched in July 2012 just before the AIDS 2012 Conference in Washington. Uses large-scale advertising and social media to spread its message. The focus is that HIV does not discriminate, we are all at risk, so everyone should be talking about HIV.
42

'Start Talking. Stop HIV' - this campaign targets MSM, by encouraging them to talk about HIV with their partners, whatever their relationship status.
43

'Testing Makes Us Stronger' & 'Take Charge. Take the Test' - these campaigns target African Americans, specifically men who have sex with men, and women.
44

Funding for prevention

In 2014, just 3 percent of the domestic HIV and AIDS budget was allocated for
prevention, making it the smallest category in the budget.
45 Yet, for every HIV infection prevented, $355,000 is saved in the costs of providing lifelong
HIV care and treatment.
4647

A CDC/John Hopkins University study, examined 5 possible 'scenarios' for the future of HIV prevention in the USA. In those scenarios where there was no increase in funding for HIV prevention efforts, there was a possible 38 percent increase in the number of people living with HIV in the USA between 2010 and 2020.
48 As a a result, maintaining current HIV prevention funding levels could cost anywhere between $128 billion to $237 billion in treatment and care costs for the US healthcare system. On the other hand, the study claimed that an investment in HIV prevention of $4.5 billion over ten years would save $104 billion in medical care costs.
49

HIV and sex education in the United States of America

The level and type of
HIV and AIDS education received by students in the USA varies depending on state regulations and the type of school or college. In some areas,
sex education that incorporates information about HIV is comprehensive and compulsory. In others, children may leave school knowing virtually nothing about HIV and AIDS.
50

Since the Welfare Reform Law earmarked $100 million for
abstinence only education in 1996, increased amounts of federal funding became available for this type of education.
51 Abstinence only education encourages people to abstain from
sex until after they are married, and does not teach people how to protect themselves during sex from
STIs and unwanted pregnancy. A number of studies have shown that abstinence only education is largely ineffective, and as a result it has proved controversial.
5253 Yet twenty-nine states still mandate that abstinence before marriage be 'stressed' in HIV education lessons at schools.
54

In his 2009 budget, Obama made a radical pledge to replace abstinence only education with funds for programmes that could “prove they delay sexual activity, increase contraceptive use and reduce teen pregnancy.”
55 However, funding for abstinence-only education has not been eliminated, but rather supplemented with funding for more comprehensive initiatives.
56

HIV testing in the United States of America

It is thought that 54 percent of American adults have ever had an
HIV test. Although more than half of the population, this still leaves a considerable proportion of people unaware of their HIV status. Of those who have not taken the test, 57 percent of them stated it's because they do not think they are at risk.
57

White Americans are least likely to have taken a test, compared to African Americans and Hispanics/Latinos who more regularly access HIV testing services. This is encouraging considering the greater extent to which these ethnicities are affected by the HIV epidemic. Still, people are testing late, and 32 percent of people in 2010 were diagnosed with AIDS just one year after testing positive for HIV.
58

Testing guidelines

In 2006, the CDC published a new set of guidelines on
HIV testing which call for automatic, routine HIV testing of all adults and adolescents attending a healthcare setting.
59 The policy allows patients to opt out if they do not wish to take a test, but removes the need for written consent and pre-test prevention counselling, which were viewed as barriers to HIV testing.

In 2010, one of the most hard-hit areas in the United States, Washington D.C, reported a 26 percent rise in the number of people tested in the previous 12 months following the implementation of routine testing, and a marketing campaign among residents to educate them about the new testing measures.
60

HIV test results

It is thought that 93 percent of people who tested for HIV in 2011 received their results, up from 69 percent in 2003.
6162 Despite this,
young people between the ages of 13-19 were the least likely to get their results (85 percent), alongside only 76 percent of
women.
63

The government's effort to distribute
rapid HIV testing kits has helped increase the number of people receiving their results, as the results can be given in as little as 20 minutes. HIV tests are offered for free on the USA’s annual HIV testing day, which takes place on 27th June.
64

In 2013, the FDA approved the first rapid HIV test that detects HIV-1 antigens, and antibodies for HIV-1 and HIV-2. Detecting antigens means that HIV can be diagnosed earlier than having to wait for the body to develop antibodies to the virus.
65 This further increases the likelihood of people obtaining their results, and sooner than before.

Mandatory testing

Whilst mandatory testing of immigrants ended in 2010, following the lifting of the HIV travel ban in January, all military personnel, and
prison inmates in certain states, are still required by law to be tested for HIV.
6667

Mandatory HIV testing among prison inmates is criticised because it can lead to the
discrimination and segregation of
HIV positive prison inmates.
68 This is evident in the state of South Carolina, and until recently in Alabama, where prisoners living with HIV are not entitled to apply for a prison job or be associated with community group pre-release programs.
69

In a 2012 trial, led by human rights groups, it was asserted that mandatory testing is a prejudiced practice that does not adhere to the Americans with Disabilities Act and should therefore be prohibited.
7071 Most AIDS organisations advocate a voluntary opt-out policy similar to that offered to pregnant women.
72

HIV and AIDS treatment and care in the United States of America

57 percent of the annual federal HIV/AIDS budget is spent on
antiretroviral treatment, reflecting the growing number of people living with HIV as treatment continues to extend life expectancies.
73

Antiretroviral treatment in the USA is available to anyone with good medical insurance. For those who are without insurance or underinsured, Medicaid, Medicare, and funding provided by the Ryan White Comprehensive AIDS Resource Emergency (CARE) Act are available to help with treatment costs.
74

The National HIV/AIDS Strategy admits "large numbers of uninsured and underinsured people with HIV mean that not everyone has sufficient access to HIV therapy".
75 The Strategy places a strong emphasis on the impact of the 2014 health care reform bill or Affordable Care Act, on the future provision of HIV treatment, such as expanded Medicaid eligibility, protection for people with pre-existing conditions that will allow them to access health insurance, and increased access to tax credits.
76

However, a considerable proportion of those who are able to access treatment are not being retained in care. A 2001-2009 study found that only 20 percent of the HIV-positive participants were considered 'highly engaged with specialist outpatient care'. Those who were most likely to be retained in high levels of care included: females as opposed to males, Hispanics and African Americans as opposed to white people, MSM as opposed to heterosexual men and drug users, those diagnosed positive at an older age, and those with lower CD4 cell counts.
77

Stigma and discrimination

The National HIV/AIDS Strategy admits "addressing
stigma and discrimination is perhaps the biggest challenge we face". This is not surprising considering the misconceptions surrounding the transmission of HIV.
78 In a 2011 survey, people were asked if they would be uncomfortable in certain situations regarding people living with HIV. The results of which shows stigma is still very much present in society today:

45 percent uncomfortable if their food was prepared by someone HIV-positive

Only 4 out of 10 people questioned reported having seen, read or heard about the USA's HIV epidemic that year, compared to 7 in 10 during 2004. Six in 10 people reported that most of what they know about HIV comes from the media, rather than schools, doctors, friends and family and religious settings.
80

Legislation has contributed to the improvement of the lives of those living with HIV and AIDS in the USA. In 1986, the government made clear to employers that they would be prosecuted if they discriminated against HIV-positive people. The ‘Americans with Disabilities Act’ now makes it illegal to discriminate against someone on the basis of their HIV status.
81

In 2010, President Obama lifted the ban on entry into the country for all HIV-positive people, which had been in place since 1987. This meant that in 2012, the biannual global conference on HIV and AIDS could be held in Washington, as previously people living with HIV would not have been able to attend.
82

Three hundred people have been convicted for exposing others to HIV in the USA. Combining the convictions in the USA and Canada equals more than all other countries in the world put together. Many of these convictions have occurred against people for spitting or biting, despite these not being
routes of HIV transmission.
83

Spending on HIV in the United States of America

The federal budget request for fiscal year (FY) 2015 included a total of $30.4 billion for domestic HIV and AIDS, a 2.3 percent increase from the FY 2014 funding, which totalled $29.7 billion. Of this, 57 percent is for care and treatment, 9 percent for research, 10 percent for cash and housing assistance, and 3 percent for prevention.
84

The HIV/AIDS Strategy acknowledges the restricted funding and makes no commitments to increase funding. Instead, it places emphasis on focused resource allocation. Funding must therefore be targeted to the highest prevalence populations and communities, including high-risk populations such as
MSM,
African Americans and Latino Americans and
PWID.
85

Conclusion

The HIV epidemic in the USA is concentrated among certain population groups such as men who have sex with men and African Americans. In order to break to cycle of transmission, greater effort needs to be made to ensure people who fall into these vulnerable groups are testing for HIV regularly, and accessing treatment.

Upscaling the treatment as prevention (TasP) approach has the potential to considerably reduce new infections. If all HIV-positive people were on antiretroviral treatment, specifically those in the most vulnerable groups, then many new transmissions could be averted.

Considering the increase in new infections among young people, a combination approach to HIV prevention education needs to be adopted and heightened, away from the historical abstinence-only approach. Young people are becoming more involved in high-risk behaviours (such as unproteced sex) at a younger age, and need to be educated about how to prevent STIs and HIV infection.